Author's response to reviews Title: Attitude toward Contraception and Abortion among Curacao women. Ineffective contraception due to limited sexual education? Authors: Marian J. van den Brink (marianvdbrink@hotmail.com) Adriana A. Boersma (adrianaboersma@hotmail.com) Betty Meyboom- de Jong (B.meyboom-de.Jong@med.umcg.nl) Jeanne G.M de Bruijn (jgmdebruijn@gmail.com) Version: 3 Date: 7 January 2011 Author's response to reviews: see over
Curaçao, 6th January 2011 Adriana Boersma, Marian van den Brink, Betty Meyboom- de Jong and Jeanne de Bruijn. Address for correspondence: A. Boersma Breedestraat (O) 33-35 Curaçao Email: adrianaboersma@hotmail.com To: Prof J. Gunn BioMed Central Editorial Response to Reviewers comments manuscript 173559071844963: Important role of socio-cultural aspects in reproductive health perceptions, knowledge and attitudes in Curaçao. Dear Prof. Jane Gunn, Thank you for your letter provisionally accepting the above article subject to certain changes being made. We have now completed the desired changes and enclose a revised submission of the above paper to be considered for publication in BMC Family Practice. We have attempted to develop the paper in line with the very helpful reviews provided by the reviewers. Below we shall state how we have undertaken the revisions by each of the reviewers. Editorial requests 1. We recommend you to copy-edit the paper to improve the style of written English. The paper has been copy edited by Biomedes (www.biomedes.co.uk) 2. Author s contributions and email addresses Full names of the authors have been written and email addresses have been added. Reviewers requests 1. Reviewer Meredith Temple-Smith Major compulsory revisions 1. Abstract: Sufficient education has been changed in respondents reported that their education on sexuality and about contraception was of good quality. The sentence Two third was not satisfied after abortion is changed in Two third was dissatisfied after abortion. The sentence with Cultural determined health beliefs in incorrect negative health consequences has been adjusted in Respondents had a negative attitude toward reliable contraceptives due to socio-cultural determined ideas about health consequences and limited sexual education. 2. Methods:
It was not clear to the reviewer that the interview had been performed on the basis of the questionnaire: Women were invited to take part in an interview by the receptionist of the general practice. If the woman agreed, the investigator interviewed the participant with the help of a questionnaire in a separate room and filled in the answers. Changes have been made to be more specific (see methods) Qualitative study: The receptionist of the general practitioner invited the women to take part; the first author interviewed all participants using the questionnaire. 2.The process of collecting and the content of the interview data have been inserted in the Method section 3. Results: The results are extremely interesting but the presentation of them was hampered in places by poor choice of English. Copy-editing has been performed by Biomedes 4. Discussion: Limitations to the study We now describe at the end of the discussion the limitations of our study. Minor essential revisions 1. Abstract Literature based questionnaire is replaced by structured interviews to investigate knowledge and attitudes towards sexuality, contraception and abortion and reasons for ineffective use of contraceptives. 2. Background 3. Social indication is replaced by on request of a woman and not on medical indication. 4. References relating to: A cultural determined hesitant attitude toward modern contraceptives and therefore limited use of them. We agree with the reviewer that the term hesitant is an unreferenced statement. We deleted the sentence. Another cultural factor could be the predominant matrifocal household, where males are only temporarily present, and where the raising of children is more a group activity of the female household and not the individual responsibility of the mother. The sentence is changed in: Another socio-cultural factor could indirectly be the predominant matrifocal household, where males are only temporarily present and relationship building between young couples is rare. We included references. (Chamberlain, M. Rethinking Caribbean families: extending the links. Community, Work & Family.2003;6:63-76. Female headed households in the Dutch Caribbean. Towards a better future. JGM de Bruijn. University of the Netherlands Antilles, 2010. ISBN 978-90-5414-190- 7.) 5. Were the two validated questionnaires used in their entirety? The used questionnaire was developed from two existing, validated questionnaires and adjusted to the local situation. The two questionnaires were not used in their entirety. Some parts of the original questionnaires were irrelevant for our situation and our research questions. The two original questionnaires had some questions in common, were we had the
choose between one of the two questionnaires. Furthermore, we added some extra questions to the questionnaire to focus on abortion and questions about the cultural context of the interviewed women. 6. The questionnaire was evaluated by two health professionals. The questionnaire was evaluated by two health professionals, experts in the field of sexuality and with experience in epidemiology, on completeness according to our research questions. and translated from Dutch into the local language, Papiamento, by two independent persons. The questionnaire was translated from Dutch into the local language, Papiamento, by two translators, both working in the medical field and independently from each other. The sensitiveness of the subject made it important to translate the questions in a proper and a polite manner. Discussing this with several professionals the most appropriate translation for each item has been chosen. A Dutch teacher working at the Fundashon di Planifikashon di Papiamento and a teacher Papiamento translated it, independently from each other, back from Papiamento in Dutch. 7. What was the role of the facility staff? The role of the facility staff was to invite women to participate in the study. They were receptionists. We changed the sentence in: The receptionist of each general practice invited women to cooperate in an interview What questions were asked? The receptionist of each general practice asked women between 15-45 years of age who were entering the waiting room if they wanted to cooperate in an research by means of an interview performed by a sixth grade medical student. If their response was positive, the receptionist explained the interview was about contraception and abortion and would take place in a separate room. If their response was negative they asked for the reason why they refused to participate. How many women agreed to be interviewed? See results first line: 92%; 146/158. 12 women refused. They refused before they knew the subject and gave lack of time as reason. How were the interview data analysed? We changed this phrase in: Most of the questions were multiple choice. We calculated the percentage of women who choosed a certain answer at each questions. The results of our data are presented in tables and the results of the qualitative questions of the interview in a descriptive way. The respondent characteristics were divided in categories and the percentage of women was calculated for each category. We compared our respondent characteristics with the data of the Central Bureau of Statistics Netherlands Antilles (http://www.cbs.an) The statistical program Statistical Package for the Social Sciences (SPSS), version 15.0 was used How many women agreed to be interviewed? 146 women were interviewed. (All women were interviewed.) For every interview, the structured questionnaire was used and completed by the same interviewer in a separate room. It is not clear where the questionnaire was completed. The women were invited to go with the investigator to a separate room where she (the investigator) interviewed the women by means of a structured interview and together they completed the questionnaire. The reason for this method:
A recent research on Curacao showed that in case of choice lower educated and older respondents prefer face to face interviews above self report questionnaires (N.van Wijk, Data administration modes and social desirability bias, 2010. Others on this subject: De Leeuw, E. D. To Mix or Not to Mix Data Collection Modes in Surveys. The Journal of Official Statistics.2005;21:233-255.) 8. The details of the question content of the questionnaire is useful, but may be better presented in a table format. If requested, we will translate parts of the questionnaire and publish it with the answers if you will publish it in an appendix. Discussion 9. Analphabetism replaced by illiteracy as you suggested. 10. There is no reference for the data on the population of Curaçao. We added the Central Bureau for Statistics of Curaçao as reference for the data on the population. 11. The meaning of the statement this means our results could be even stronger than than presented is unclear. We agree with the reviewer that the meaning of this statement is unclear and we deleted the paragraph. Conclusion 12. Due to comparable Caribbean socio-cultural aspects is indeed also unclear. We made changes in this paragraph and left this phrase out.
2. Reviewer Hong He 1-4 5. Discussion and conclusion not adequately supported by the data: a. Questions about socio-cultural aspects in the questionnaire: The respondents represent Curacao women. Their knowledge about contraception and their attitude toward contraception and abortion is the result of the culture in Curacao which does not allow sufficient sexual education. Socio-cultural aspects have an important role in reproductive health perceptions, knowledge and attitudes in Curacao. We made changes in the discussion, conclusion and abstract. b. Students represent 35%, so the data should be analysed by different groups. The subgroups were too small to analyse separately. A professional statistician at the University of Groningen in the Netherlands advised us in this matter. We changed students in pupils and students. Most of them were women who went back to school after they dropped out of school some years before. The number of pupils and students in Curaçao is according to the Central Bureau for Statistics of Curaçao approximately 35.000 (primairy, secundairy and tertiairy education). The population of Curacao is appr. 140.000 (CBS Curacao, Census 2001). c. Main economic factors were prices of contraceptive methods and no insurance coverage. In Curaçao most insurance companies do not cover for contraceptives, so not only the 3% without insurance has to pay for contraception but approximately 70%. We changed the sentence in: Main economic factors were prices of contraceptive methods, because most insurances in Curaçao do not cover contraceptives. d. Most respondents stated that abortion is not a good method of contraception and saw abortion as a risky procedure. Nevertheless a lot of them ran the risk of an unplanned pregnancy and certainly some would have an abortion. It is a contrast how they think about abortion and what they do if necessary. The conclusion is that they see abortion as an emergency procedure. But they do not anticipate by choosing to use reliable contraceptives and take the high risk they will need abortion. 6. Limitations of the study are not clearly stated We now describe at the end of the discussion the limitations of our study. 7. Do the authors clearly acknowledge any work upon which they are building, both published and unpublished? No. The origin of the questionnaire is now extensively described in the method section and we added references. 8. Do the title and abstract accurately convey what has been found? No We agree with the reviewer and changed the title in: Attitude toward Contraception and Abortion among Curaçao women. Ineffective contraception due to limited sexual education?
In sum, the methods have been revised considerably, unclear phrases have been adjusted, we skipped unusual terminology, limitations to the study are described in the discussion and we changed the title. We feel that the paper is more coherent and we would like to thank the reviewers for their feedback and the editorial board for their helpful guidance. Yours sincerely, Adriana Boersma, Marian van de Brink, Betty Meyboom- de Jong and Jeanne de Bruijn.